Pediatric Advanced Life Support (PALS) 
American Heart Association Year 2000 Guidelines

CONTENTS

Pediatric Rollout Overview

PBLS Specific Highlights

PALS Specific Highlights

Proposed Video for PALS

Neonatal Resuscitation Guidelines

Pediatric Rollout Overview

1. New international consensus on science: Evidence basis of new guidelines, with attention to ease of teaching and retention

2. K.I.S.S. principle: Simplify when possible

3. Reliance on instructor consistency: Teaching adjuncts (videos, scripted case scenarios, delineation of core vs supplementary materials) with increased emphasis on consistent reinforcement of core goals

4. Emphasis of targeting of provider to make scenarios more realistic to scope of provider's care: Introduction of selected modules targeted to provider needs including Coping With Death and Dying, Trauma and Spinal Immobilization, Sedation, Rapid Sequence Intubation, Resuscitation of the Newly Born Outside of the Delivery Room, Special Resuscitation Circumstances-Toxicology, Children With Special Health Care Needs.

5. Expectation for student and instructor preparation for course: Introduction of mandatory completion of pretest and expectation that students have read core elements of Course Manual and Text PRIOR to attending the course. Separation of text into course manual/study guide section and resource text chapters, with core material clearly delineated. Use of annotated pretest to facilitate student self-evaluation.

6. Less lecture/more time hands-on in skills stations and case scenario practice: Effort is to visually demonstrate features of key assessment and interventions (eg, child with respiratory distress, shock, bag-mask ventilation, tracheal intubation, intraosseous insertion) using video segments for consistency, instead of slide/lecture format and then rapidly segue to hands-on demonstration in skills station.

7. Increased use of video to demonstrate skills and assessments: Effort to improve consistency of instructor message, while preserving the value and contribution of expert local instructor.

8. Plans for future expansion to alternative electronic modes of demonstration, study and evaluation.

PBLS Specific Highlights

1. SIMPLIFY lay rescuer courses to improve retention. For example: Lay rescuer courses will not include instruction on FBAO for unresponsive victims; CPR technique will be followed instead.

1A. The pulse check is deleted as a mandatory assessment for lay providers, "signs of circulation" are substituted.

[Demonstration of "signs of life": breathing, movement, response to stimulation rather than pulse check: review of false-positive and false-negative numbers and consequences]

2. Use of AEDs is encouraged for victims of cardiac arrest more than approximately 8 years of age or more than approximately 25 kg (55lbs), although data regarding the use of AEDs in this age group is limited.

[Demonstration of placement of AED pads on child >8 years of age in AP position: review of indications and lack of data for younger children]

3. Bag-mask ventilation is a skill that all BLS healthcare providers should master.

[Demonstration of E-C clamp technique for 1 and 2 rescuers, with emphasis that respiratory compromise is No. 1 cause of infant and child emergencies]

4. Special situations should be recognized (phone first vs. phone fast), especially for victims with sudden collapse and/or risk factors for VF to access rapid defibrillation.

[Demonstration of features that suggest primary cardiac cause and "phone first" mentality: sudden collapse, history of cardiac disease, known overdose of tricyclic antidepressant or digoxin]

5. Two thumb-encircling hands chest compression technique is preferred for healthcare providers over the 2-finger compression technique for infants.

[Demonstration of 2 thumb-encircling hand technique: explanation that for simplicity, lay rescuers and single healthcare providers are taught only 2-finger, but when more than 1 healthcare provider are present, 2-thumb is recommended]

6. Chest compression-ventilation ratio for 1 or 2 rescuers of pediatric victims remains 5:1.

[Demonstration of 5:1 CV ratio: review of rationale for remaining 5:1 for 1 or 2 rescuers, lay or healthcare provider, and emphasis of pause for ventilation with unprotected airway to ensure adequate ventilation]

7. Consideration of alternative airway devices (LMA) for trained healthcare providers.

[Demonstration of LMA as example of consideration of adjuncts and reminder that Combitube and esophageal obturator airways are not recommended for infants and children]

8. Audio-prompts may help the rescuer train and perform CPR at suggested rates.

[Demonstration of audio-prompt during training of 5:1 ratio]

9. Consider a recovery position for unresponsive victims with signs of circulation and breathing.

[Demonstrate features of a reasonable recovery position: review of issues in trauma, pressure points and importance of maintaining surveillance of airway and breathing]

10. Lack of evidence and caution for application of adult advanced CPR adjuncts in pediatrics

[Demonstrate interposed abdominal compression CPR (IAC-CPR) and reinforce lack of data to support routine application of IAC-CPR, active compression-decompression CPR (ACD-CPR), vest CPR, minimally invasive CPR, open chest CPR, and extracorporeal life support in pediatrics]

PALS Specific Highlights

Goals of the PALS course are to provide the participants with the information and strategies to

• Prevent injury and death in infants and children
• Recognize and initiate treatment for infants and children with impending respiratory failure, shock, and cardiopulmonary arrest.
  • Provide BLS - Provide advanced support of oxygenation and ventilation
  • Obtain vascular access
  • Initiate appropriate resuscitative fluid and drug therapy
• Support families and providers in coping with emergencies and death

1. Simplification of education and reinforcement of skill acquisition and core competencies are essential in all American Heart Association (AHA) courses.

[Core objectives of PALS course: (1) Prevent injury and death in infants and children, (2) Recognize and initiate treatment for infants and children with impending respiratory failure, shock, and cardiopulmonary arrest, (3) Support families and providers in coping with emergencies and death]

2. Emphasis on effective bag-mask ventilation by all ALS providers and tracheal intubation in unconscious patients attempted only by healthcare providers trained and experienced in performing this skill.

[Demonstration of E-C clamp technique of BM ventilation for 1- and 2-rescuer CPR, and endotracheal view of intubation: review of caveats explaining that level of training and available equipment and CQI locally should determine best ALS airway/ventilation support for a given system]

3. Emphasis on secondary confirmation of tracheal tube position (exhaled CO2 for patients with perfusing rhythms)

[Demonstration of exhaled CO2 assessment in patient with perfusing rhythm: review of caveats for patients with "collapse" rhythms and infants <2 kg; considerations for initial confirmation and continuous monitoring; qualitative vs quantitative waveform information]

4. Attention to cardiac arrest and cardiovascular emergencies related to special resuscitation circumstances (eg, drug overdoses, toxins, electrolyte abnormalities, asthma, and anaphylaxis)

[Demonstration of special resuscitation circumstances that might trigger deviation from "usual algorithm": example of early bicarbonate treatment for known or suspected TCA overdose with arrhythmia; early treatment of PEA secondary to tension pneumothorax (using D.O.P.E. mnemonic; use of teaching tool (4 H's and 4 T's) in pulseless arrest algorithm]

5. Increased attention to early vascular access, including IO, even for victims >6 years of age

[Demonstration of IO insertion in older child and consideration of alternative sites]

6. Automated external defibrillators (AEDs) may be used in the treatment of children >8 years of age in cardiac arrest

[Demonstration of AED use in child >8 years of age; review of caveats for use and indeterminate class of recommendation for alternative waveforms in children]

7. Increased emphasis on postresuscitation interventions that may influence neurological survival

[Demonstration of attention to control of temperature and avoidance of hyperthermia; monitoring glucose (using non-glucose-containing fluids during resuscitation and checking bedside glucose), support of post-arrest myocardial dysfunction (inotropes, vasodilators, inodilators) and monitoring of exhaled CO2 to normal physiologic levels]

8. Consideration of alternative airway adjuncts (LMA)

[Demonstration of LMA as example of adjunct as above for PBLS]

9. Introduction of vagal maneuvers into the treatment algorithm for supraventricular tachycardia

[Demonstration of ice water to face in infant and child blowing through straw; show tachycardia algorithms including consideration of vagal maneuvers, emphasize early expert consultation when available]

10. Medications for pulseless arrest

[Demonstration of pulseless arrest algorithm reviewing de-emphasis of high dose epinephrine (special circumstances), lack of data on vasopressin in children, consideration of amiodarone for VF/VT included based upon adult extrapolation and pediatric non-arrest data]

11. Medications for pediatric wide complex tachycardia and introduction of the drug amiodarone into the treatment algorithms for pediatric VT

[Demonstration of tachycardia algorithm showing inclusion of consideration of amiodarone, procainamide and avoidance of concurrent use of drugs which prolong QTc, utility of these drugs for narrow and wide complex tachycardia, consideration of magnesium, de-emphasis of lidocaine and removal of bretylium]

Proposed Video for PALS

Neonatal Resuscitation Guidelines

1. Special situations should be recognized in the delivery room, especially for infants with meconium aspiration risk including direct tracheal suctioning to remove meconium from the airway only when a newly born infant has absent or depressed respirations, heart rate <100 bpm, or poor muscle tone

[Demonstration of newly born infant being suctioned for meconium (not direct tracheal) in vigorous infant. Review conditions in which tracheal meconium suctioning is recommended]

2. Simplified guideline to provide chest compressions if the heart rate is absent or remains <60 bpm despite adequate assisted ventilation for 30 seconds, with guidance by a relative depth of compression (one third of the anterior-posterior diameter of the chest) rather than an absolute depth, and using the "two thumb-encircling hands" chest compression technique as the preferred technique.

[Demonstration of 2-thumb technique by 2 providers in resuscitation of a newly born infant with emphasis on effective ventilation and ease of provider retention]

3. Preference for initial volume resuscitation with crystalloid, avoiding albumin-containing solutions

[Demonstration of crystalloid volume infusion, with notation that most infants are euvolemic or hypervolemic and therefore initial bolus is still recommended as 10mL/kg rather than 20mL/kg, with routine preference for crystalloid, except when blood loss is suspected cause…then use blood]

4. Hyperthermia should be avoided, and active cerebral hypothermia treatment of perinatal asphyxia is under active investigation but cannot be routinely recommended at this time.

[Demonstration of attention to infant temperature control with thermometer]

5. Discussion of circumstances (relating to gestational age, birth weight, known underlying condition, lack of response to interventions) in which noninitiation or discontinuation of resuscitation in the delivery room may be appropriate

[Discussion of team stopping resuscitation and offering support to family. Consider Coping With Death and Dying modules, and family presence during resuscitation issues]

6. Emphasis that personnelcapable of initiating resuscitation should attend every delivery

[Review definition of newly born, neonate, and infant and emphasis in PALS course on the newly born OUTSIDE the delivery room]

7. Emphasis on effective bag-mask ventilation by all ALS providers and tracheal intubation in unconscious patients attempted only by healthcare providers trained and experienced in performing this skill

[Demonstration of EC clamp technique on newly born infant with emphasis on training and CQI]

8. Continue to coordinate chest compressions with ventilations at a ratio of 3:1 and a rate of 120 events per minute to achieve approximately 90 compressions and 30 breaths per minute.

[Demonstration of 120 events per minute delivery and caveat on difference between PALS and NRP emphasis]

9. Data is insufficient to justify a change from the recommendation that 100% oxygen be used if assisted ventilation is required and oxygen is available.

[Demonstration of 100% O2 delivery vs room air, with voiceover of caveat]

10. Consideration of alternative airway adjuncts (LMA), when used by appropriately trained providers.

[Demonstration of LMA in newly born as example of alternative adjuncts]

11. Consideration for secondary confirmation of tracheal tube position

[Demonstration of exhaled CO2 with caveat of >2 kg and perfusing rhythm]

12. Intraosseous access can be used as an alternative route for medications/volume expansion if umbilical or other direct venous access is not readily available.

[Review of IO insertion in term newly born infant with emphasis on use of technique that provider is most familiar with (IO vs umbilical vein catheterization)]

SEE ALSO: PBLS (Pediatric Basic Life Support)
Ethical Aspects of CPR and ECC,
Adult BLS (Basic Life Support), 
Link to Template for PALS Class,
PALS Rollout Agenda and Equipment Needed,
PALS Textbook,
and ACLS (Advanced Cardiac Life Support)

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